Missouri Code of State Regulations
Title 13 - DEPARTMENT OF SOCIAL SERVICES
Division 70 - MO HealthNet Division
Chapter 15 - Hospital Program
Section 13 CSR 70-15.010 - Inpatient Hospital Services Reimbursement Methodology
Universal Citation: 13 MO Code of State Regs 70-15.010
Current through Register Vol. 49, No. 18, September 16, 2024
PURPOSE: This proposed amendment adds a new supplemental payment paid to hospitals.
(1) General Reimbursement Principles.
(A) For inpatient hospital services provided
for an individual entitled to Medicare Part A inpatient hospital benefits and
eligible for MO HealthNet, reimbursement from the MO HealthNet Program will be
available only when MO HealthNet's applicable payment schedule amount exceeds
the amount paid by Medicare. MO HealthNet's payment will be limited to the
lower of the deductible and coinsurance amounts or the amount the MO HealthNet
applicable payment schedule amount exceeds the Medicare payments. For all other
MO HealthNet participants, unless otherwise limited by rule, reimbursement will
be based solely on the individual participant's days of care (within benefit
limitations) multiplied by the individual hospital's Title XIX per diem
rate.
(B) The Title XIX
reimbursement for hospitals, excluding those located outside Missouri, shall
include the payments as outlined below. Reimbursement shall be subject to
availability of federal financial participation (FFP).
1. Inpatient per diem reimbursement is
established in accordance with sections (4) and (5).
2. Outpatient reimbursement is established in
accordance with 13 CSR 70-15.160.
3. Acuity adjustment payment (AAP) is
established in accordance with section (6).
4. Poison control (PC) payment is established
in accordance with section (7).
5.
Stop loss payment (SLP) is established in accordance with section
(8).
6. Disproportionate share
hospital (DSH) payment is established in accordance with
13 CSR
70-15.220.
7. Graduate medical education (GME) payment
is established in accordance with section (9).
8. Upper payment limit (UPL) payment is
established in accordance with
13 CSR
70-15.230.
9. Children's outlier (CO) payment is
established in accordance with section (10).
10. Psych adjustment (PA) payment is
established in accordance with section (11).
(C) The Title XIX reimbursement for hospitals
located outside Missouri will be established in accordance with 13 CSR
7015.190.
(2) Definitions.
(A) Allowable costs. Allowable
costs are those related to covered MO HealthNet services defined as allowable
in 42 CFR chapter IV, part 413, except as specifically excluded or restricted
in 13 CSR 7015.010 or the MO HealthNet hospital provider manual and detailed on
the audited Medicaid cost report. Penalties or incentive payments as a result
of Medicare target rate calculations shall not be considered allowable costs.
Implicit in any definition of allowable cost is that this cost is allowable
only to the extent that it relates to patient care; is reasonable, ordinary,
and necessary; and is not in excess of what a prudent and cost-conscious buyer
pays for the given service or item.
(B) Bad debt. Bad debts include the costs of
caring for patients who have insurance but are not covered for the particular
services, procedures, or treatment rendered. Bad debts do not include the cost
of caring for patients whose insurance covers the given procedures but limits
coverage. In addition, bad debts do not include the cost of caring for patients
whose insurance covers the procedure although the total payments to the
hospital are less than the actual cost of providing care.
(C) Base year cost report. Audited Medicaid
cost report from the third prior calendar year. If a facility has more than one
(1) cost report with periods ending in the third prior calendar year, the cost
report covering a full twelve- (12-) month period will be used. If none of the
cost reports covers a full twelve (12) months, the cost report with the latest
period will be used. If a hospital's base year cost report is less than or
greater than a twelve- (12-) month period, the data shall be adjusted, based on
the number of days reflected in the base year cost report to a twelve- (12-)
month period. Any changes to the base year cost report after the division
issues a final decision on assessment or payments will not be included in the
calculations.
(D) Case mix index
(CMI). The hospital CMI for the AAP is determined based on the hospital's MO
HealthNet inpatient claims and 3MTM All-Patient
Refined Diagnosis Related Groups (APR-DRG) software, a grouping algorithm to
categorize inpatient discharges with similar treatment characteristics
requiring similar hospital resources.
1. For
State Fiscal Year (SFY) 2023, each hospital's CMI was calculated as follows:
A. A dataset of complete inpatient stays was
established using MO HealthNet fee-for-service claims and managed care
encounters combined for calendar years 2019 and 2020. A two-(2-) year dataset
was used to account for the potential impact of changes to hospital
utilization, costs, and mix of patients due to the COVID-19 public health
emergency;
B. Interim claims where
multiple claims cover a single inpatient stay were combined into single claims
covering the complete inpatient stay;
C. The 3MTM
APR-DRG grouping software was applied to the inpatient dataset, using version
38 of the grouper. Each inpatient stay was assigned to a single DRG and
severity of illness level. Each APR-DRG is associated with a relative weight
reflecting the relative amount of resources required to care for similar stays,
compared to an average inpatient stay. APR-DRG weights are provided by
3MTM and are calculated based on a national all
payer population;
D. The national
weights were recentered to reflect the average resource requirements within the
MO HealthNet population, including both fee-for-service and managed care
encounter inpatient stays. Recentered weights are calculated by dividing the
APR-DRG national weights by the average case mix for all hospitals. The average
case mix is calculated as the sum of the national weights for each inpatient
stay divided by the number of stays for all hospitals;
E. A hospital-specific CMI is calculated by
summing the MO HealthNet recentered weights for each inpatient stay and
dividing the total by the number of inpatient stays for the hospital.
2. For SFY 2024 and forward, the
basis of the case mix index will be determined by the division based on
combined inpatient stays from the second and third prior calendar years, the
current version of the 3MTM APR-DRG grouper,
relative weights appropriate for the MO HealthNet population, and the SFY in
which an AAP is being calculated.
(E) Charity care. Results from a provider's
policy to provide health care services free of charge or a reduction in charges
because of the indigence or medical indigence of the patient.
(F) Contractual allowances. Difference
between established rates for covered services and the amount paid by
third-party payers under contractual agreements.
(G) Cost report. A cost report details, for
purposes of both Medicare and MO HealthNet reimbursement, the cost of rendering
covered services for the fiscal reporting period. The Medicare/Medicaid Uniform
Cost Report contains the forms utilized in filing the cost report. The
Medicare/Medicaid Cost Report version 2552-10 (CMS 2552-10) shall be used for
fiscal years beginning on and after May 1, 2010.
(H) Division. Unless otherwise designated,
division refers to the MO HealthNet Division (MHD) a division of the Department
of Social Services charged with the administration of the MO HealthNet
program.
(I) Medicaid inpatient
days. Medicaid inpatient days are paid Medicaid days for inpatient hospital
services as reported by the Medicaid Management Information System (MMIS).
(J) Nonreimbursable items. For
purposes of reimbursement of reasonable cost, the following are not subject to
reimbursement:
1. Allowances for return on
equity capital;
2. Amounts
representing growth allowances in excess of the intensity allowance, profits,
efficiency bonuses, or a combination of these;
3. Cost in excess of the principal of
reimbursement specified in 42 CFR chapter IV, part 413; and
4. Costs or services specifically excluded or
restricted in this rule or the MO HealthNet hospital provider manual.
(K) Reasonable cost. The
reasonable cost of inpatient hospital services is an individual hospital's
Medicaid cost per day as determined in accordance with section (4) of this
regulation using the base year cost report.
(L) Specialty pediatric hospital. An
inpatient pediatric acute care facility which-
1. Is licensed as a hospital by the Missouri
Department of Health and Senior Services under Chapter 197 of the Missouri
Revised Statutes;
2. Has been
granted substantive waivers by the Missouri Department of Health and Senior
Services from compliance with material hospital licensure requirements
governing a) the establishment and operation of an emergency department, and b)
the provision of pathology, radiology, laboratory, and central services;
and
3. Is not licensed to operate
more than sixty (60) inpatient beds.
(M) Trend factor. The trend factor is a
measure of the change in costs of goods and services purchased by a hospital
during the course of one (1) year.
(N) Federal reimbursement allowance (FRA).
The fee assessed to hospitals for the privilege of engaging in the business of
providing inpatient health care in Missouri. The FRA shall be an allowable cost
to the hospital. The FRA is identified in 13 CSR 7015.110. Effective January 1,
1999, the assessment shall be an allowable cost.
(O) Incorporation by reference. This rule
incorporates by reference the following:
1.
The Hospital Provider Manual is incorporated by reference and
made a part of this rule as published by the Department of Social Services, MO
HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its
website at http://manuals.momed.com/manuals/,
June 8, 2022. This rule does not incorporate any subsequent amendments or
additions;
2. Medicare/Medicaid
Cost Report CMS 2552-10, which is incorporated by reference and made a part of
this rule as published by the Centers for Medicare & Medicaid Services
(CMS) at its website
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Paper-Based-Manuals-Items/CMS021935.html,
June 8, 2022. This rule does not incorporate any subsequent amendments or
additions; and
3.42 CFR
413, which is incorporated by reference and
made a part of this rule as published by the U.S. Government Publishing Office
and available at
https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-413?toc=1,
June 8, 2022. This rule does not incorporate any subsequent amendments or
additions. Only the cost principles from
42 CFR
413 are incorporated by
reference.
(3) Reporting Requirements.
(A) Cost reports.
1. Each hospital participating in the MO
HealthNet program shall submit a cost report in the manner prescribed by the
division. The cost report shall be submitted within five (5) calendar months
after the close of the reporting period. The period of a cost report is defined
in 42 CFR
413.24(f).
A. All cost reports shall be submitted and
certified by an officer or administrator of the hospital.
B. If a cost report is more than ten (10)
days past due, the division may withhold fifty thousand dollars ($50,000) in MO
HealthNet payments from the hospital until the hospital submits the cost
report. If the MO HealthNet payment is less than fifty thousand dollars
($50,000), the entire payment will be withheld. Upon the division's or its
authorized contractor's receipt of the cost report prepared in accordance with
this regulation, the payment that was withheld will be released to the
hospital.
C. A single extension,
not to exceed thirty (30) days, may be granted upon the request of the hospital
and the approval of the division when the hospital's operation is significantly
affected due to extraordinary circumstances over which the hospital had no
control, such as fire or flood. The request must be in writing and postmarked
prior to the first day of the sixth month following the hospital's fiscal year
end.
2. The change of
control or ownership of a hospital of participation in the program requires
that the hospital submit a cost report for the period ending with the date of
change of control or ownership within five (5) calendar months after the close
of the reporting period.
A. Upon learning of
a change of control or ownership, the division may withhold fifty thousand
dollars ($50,000) of the next available MO HealthNet payment from the hospital
identified in the current MO HealthNet participation agreement until the cost
report is filed. If the MO HealthNet payment is less than fifty thousand
dollars ($50,000), the entire payment will be withheld. Once the cost report
prepared in accordance with this regulation is received, the payment will be
released to the hospital identified in the current MO HealthNet participation
agreement.
B. The division may, at
its discretion, delay the withholding of funds specified in subparagraph
(3)(A)2.A. until the cost report is due based on assurances satisfactory to the
division that the cost report will be timely filed. A request jointly submitted
by the buying and selling entities may provide adequate assurances. The buying
entity must accept responsibility for ensuring timely filing of the cost report
and authorize the division to immediately withhold fifty thousand dollars
($50,000) if the cost report is not timely filed.
3. The termination of or by a hospital of
participation in the MO HealthNet program requires that the hospital submit a
cost report for the period ending with the date of termination within five (5)
calendar months from the date of the CMS tie-out notice. No extension in the
submitting of cost reports shall be allowed when a termination of participation
has occurred.
A. Upon learning of the
termination, the division may withhold fifty thousand dollars ($50,000) of the
next available MO HealthNet payment from the hospital until the cost report is
filed. If the MO HealthNet payment is less than fifty thousand dollars
($50,000), the entire payment will be withheld. Upon the division's or its
authorized contractor's receipt of the cost report prepared in accordance with
this regulation, the payment that was withheld will be released to the
hospital.
4. Amended cost
reports or other supplemental. The division or its authorized contractor will
notify the hospital by letter when the audit of its cost report is completed.
Since this data will be used in the calculation of per diem rates, and other
Medicaid payments, the hospital shall review the audited cost report data and
submit amended or corrected data to the division or its authorized contractor
within fifteen (15) days. Data received after the fifteen- (15-) day deadline
will not be considered by the division for per diem rates, or other Medicaid
payments unless the hospital requests in writing and receives an extension to
file additional information prior to the end of the fifteen- (15-) day
deadline.
(B) Records.
1. All hospitals are required to maintain
financial and statistical records in accordance with
42 CFR
413.20. For purposes of this plan,
statistical and financial records shall include beneficiaries' medical records
and patient claim logs separated for inpatient and outpatient services billed
to and paid for by MO HealthNet (excluding cross-over claims) respectively. All
records must be available upon request to representatives, employees, or
contractors of the MO HealthNet program, Missouri Department of Social
Services, General Accounting Office (GAO), or the United States Department of
Health and Human Services (HHS). The content and organization of the inpatient
and outpatient logs shall include the following:
A. A separate log for each fiscal year must
be maintained by either date of service or date of payment for claims and all
adjustments of those claims for services provided in the fiscal period. Lengths
of stay covering two (2) fiscal periods should be recorded by date of
admission. The information from the log should be used to complete the Medicaid
worksheet in the hospital's cost report;
B. A year-to-date total must appear at the
bottom of each log page or after each applicable group total, or a summation
page of all subtotals for the fiscal year activity must be included with the
log; and
C. Not to be included in
the logs are denied claims or line item charges. This would include payments
for hospital-based physicians and certified registered nurse anesthetists
billed by the hospital on a professional services claim or payments for
services provided by the hospital through enrollment as a MO HealthNet
provider-type other than hospital.
2. Records of related organizations, as
defined by 42 CFR
413.17, must be available upon demand to
those individuals or organizations as listed in paragraph (3)(B)1. of this
rule.
(C) Cost report
audits.
1. The examination or inspection of a
hospital's cost report, files, and any other supporting documentation by the
division or its authorized contractor. The division or its authorized
contractor may perform the following types of audits:
A. Level I audit-Requires a more narrow scope
of review of hospital cost reports, files, and any other additional information
requested and submitted to the division or its authorized contractor. The
limited review may include items such as comparative analysis of a hospital's
cost report data to industry data, a review of a hospital's prior year data to
determine any outliers that may warrant further review, requesting additional
details of the reported information, all of which could lead to potential
adjustment(s) after such further review, as well as making standard
adjustments, etc. Level I audits may be provided off-site;
B. Level II Audit-Requires a desk review of
hospital cost reports, files, and any other additional information requested
and submitted to the division or its authorized contractor. The desk review may
include review procedures in a level I audit plus a more detailed analysis of a
hospital's cost report data to identify items that would require further review
including requesting additional details of the reported information,
documentation to support amounts reflected in the cost report, etc. Level II
audits may be provided off-site; or
C. Level III audits-Requires an in depth
audit, including an on-site review, of hospital cost reports, files, and any
other additional information requested and submitted to the division or its
authorized contractor. The level III audit will require an in depth analysis of
a hospital's cost report data and an on-site verification of cost report items
deemed necessary through a risk assessment or other analyses, etc. Level III
audits will require some portion of the hospital's records review be provided
on-site.
(4) Inpatient Per Diem Reimbursement Rate Computation. Effective for dates of service beginning July 1, 2022, each Missouri hospital shall receive a Missouri Medicaid per diem rate based on the following computation:
(A) The
per diem shall be determined from the base year cost report in
accordance with the following formula:
1. MIP FRA-Medicaid
inpatient share of FRA. The Medicaid inpatient share of the FRA Assessment will
be calculated by dividing the hospital's Medicaid fee-for-service (FFS) and
managed care (MC) inpatient days from the base year cost report by total
hospital inpatient days from the base year cost report to arrive at the
Medicaid utilization percentage. This percentage is then multiplied by the
inpatient FRA assessment for the current SFY to arrive at the increased
allowable Medicaid cost. This cost is then divided by the estimated Medicaid
FFS and MC days for the current SFY to arrive at the increased Medicaid cost
per day. The estimated Medicaid FFS and MC days are paid days from the second
prior calendar year;
2.
MPD-Medicaid inpatient days from the base year cost report;
3. TI-Trend indices. The trend indices are
applied to the TAC per day of the per diem rate. The trend
index for the base year is used to adjust the TAC per day to a common fiscal
year end of June 30. The adjusted TAC per day shall be trended through the
current SFY;
4. TAC-Medicaid
allowable inpatient routine and special care unit costs, and ancillary costs,
from the base year cost report, will be added to determine the hospital's
Medicaid total allowable cost (TAC);
5. The per diem for private
free-standing psychiatric hospitals shall be the greater of one-hundred percent
(100%) of the SFY 2022 weighted average statewide per diem
rate for private free-standing psychiatric hospitals or the per
diem as calculated in subsection (4)(A);
6. The per diem shall not
exceed the average Medicaid in patient charge per diem as
determined from the base year cost report and adjusted by the TI; except for
federally deemed critical access hospital's whose Medicaid FFS charges equal
sixty percent (60%) or less of its Medicaid FFS costs;
7. The per diem shall be
adjusted for rate increases granted in accordance with subsections (4)(C) and
(4)(D);
8. If the hospital does not
have a base year cost report, the inpatient per diem will be
the weighted average statewide per diem rate as determined in
section (5);
(B) Trend
indices (TI). For trend indices for State Fiscal Year (SFY) 2018 and forward,
refer to the Hospital Market Basket index as published in Healthcare Cost
Review by Institute of Health Systems (IHS), or equivalent publication,
regardless of any changes in the name of the publication or publisher, for each
SFY;
(C) Adjustments to rates. A
hospital's inpatient per diem rate may be adjusted only under
the following circumstances:
1. When
information contained in the cost report is found to be intentionally
misrepresented. Such adjustment shall be made retroactive to the date of the
original rate. Such adjustment shall not preclude the division from imposing
any sanctions authorized by any statute or regulation; and
2. When a rate reconsideration is granted in
accordance with subsection (4)(D);
(D) Rate reconsideration.
1. Rate reconsideration may be requested
under this subsection for changes in allowable costs which occur subsequent to
the base year cost report described in subsection (4)(A). The effective date
for any increase granted under this subsection shall be no earlier than the
first day of the month following the division's final determination of the rate
reconsideration.
2. The following
may be subject to review under procedures established by the division:
A. New or expanded inpatient services. A
hospital, at times, may offer to the public new or expanded inpatient services
which may require certificate of need (CON) approval.
(I) A state hospital, i.e., one owned or
operated by the Board of Curators as provided for in Chapter 172, RSMo, or one
owned or operated by the Department of Mental Health, may offer new or expanded
inpatient services to the public provided it receives legislative
appropriations for the project. A state hospital may submit a request for
inpatient rate reconsideration if the project meets or exceeds a cost threshold
of one (1) million dollars for capital expenditures or one (1) million dollars
for major medical equipment expenditures as described in 19 CSR
6050.300.
(II) Non-state hospitals,
may also offer new or expanded inpatient services to the public, and incur
costs associated with the additions or expansions which may qualify for
inpatient rate reconsideration requests. Such projects may require a CON. Rate
reconsideration requests for projects requiring CON review must include a copy
of the CON program approval. Non-state hospitals may request inpatient rate
reconsiderations for projects not requiring review by the CON program, provided
each project meets or exceeds a cost threshold of one (1) million dollars for
capital expenditures as described in
19 CSR
60-50.300.
(III) A hospital (state or non-state) will
have six (6) months after the new or expanded service project is completed and
the service is offered to the public to submit a request for inpatient rate
reconsideration, along with a budget of the project's costs. The rate
reconsideration request and budget will be subject to review. Upon completion
of the review, the hospital's inpatient reimbursement rate may be adjusted, if
indicated. Failure to submit a request for rate reconsideration and project
budget within the six- (6-) month period shall disqualify the hospital from
receiving a rate increase prior to recognizing the increase through the trended
cost calculation.
(IV) Rate
reconsiderations due to new or expanded services will be determined as total
allowable project cost (i.e., the sum of annual depreciation, annualized
interest expense, and annual additional operating costs) multiplied by the
ratio of total inpatient costs (less SNF and swing bed cost) to total hospital
cost as submitted on the most recent cost report filed with the division or its
authorized contractor as of the review date divided by total acute care patient
days including all special care units and nursery, but excluding swing bed
days. The most recent cost report filed must be audited prior to the
finalization of the rate reconsideration.
(V) Total acute care patient days (excluding
nursery and swing bed days) must be at least sixty percent (60%) of total
possible bed days. Total possible bed days will be determined using the number
of licensed beds times three hundred sixty-five (365) days. If the total acute
care patient days (excluding nursery and swing bed days) are less than sixty
percent (60%) of total possible bed days, the sixty percent (60%) number plus
nursery days will be used to determine the rate increase. If the total acute
care patient days (excluding nursery and swing bed days) are at least sixty
percent (60%) of total possible bed days, the total acute care patient days
plus nursery days will be used to determine the rate increase. This computation
will apply to capital costs only.
(VI) Major medical equipment costs included
in rate reconsideration requests shall not include costs to replace current
major medical equipment if the replacement does not result in new or expanded
inpatient services. The replacement of inoperative or obsolete major medical
equipment, by itself, does not qualify for rate reconsideration, even if the
new equipment costs at least one (1) million dollars; and
B. When the hospital experiences
extraordinary circumstances which may include but are not limited to an act of
God, war, or civil disturbance.
3. The following will not be subject to
review under these procedures:
A. The use of
Medicare standards and reimbursement principles;
B. The method for determining the trend
factor;
C. The use of all-inclusive
prospective reimbursement rates; and
D. Increased costs for the successor owner,
management or leaseholder that result from changes in ownership, management,
control, operation, or leasehold interests by whatever form for any hospital
previously certified at any time for participation in the Medicaid
program.
4. The request
for a rate reconsideration must be submitted in writing to the division and
must specifically and clearly identify the project and the total dollar amount
involved. The total dollar amount must be supported by generally accepted
accounting principles. The hospital shall demonstrate the rate reconsideration
is necessary, proper, and consistent with efficient and economical delivery of
covered patient care services. The hospital will be notified of the division's
decision in writing within sixty (60) days of receipt of the hospital's written
request or within sixty (60) days of receipt of any additional documentation or
clarification which may be required, whichever is later. Failure to submit
requested information within the sixty (60) day period, shall be grounds for
denial of the request.
(5) Per Diem Reimbursement Rate Computation for New Hospitals. Effective for dates of service beginning July 1, 2022, each new Missouri hospital's rate setting cost report shall be the first full fiscal year cost report, which includes inpatient Medicaid costs, otherwise the hospital shall continue to receive the weighted average statewide per diem rate as determined below.
(A)
Acute care hospitals. In the absence of adequate cost data, a new hospital's
Medicaid rate shall be one-hundred percent (100%) of the weighted average
statewide per diem rate for acute care hospitals until a
prospective rate is determined on the hospital's rate setting cost report, in
accordance with section (4).
(B)
Free-standing psychiatric hospitals. In the absence of adequate cost data, a
new hospital's Medicaid rate shall be one hundred percent (100%) of the
weighted average statewide per diem rate for free-standing
psychiatric hospitals, excluding the state psychiatric hospitals, until a
prospective rate is determined on the hospital's rate setting cost report, in
accordance with section (4).
(C)
Long term acute care hospitals. In the absence of adequate cost data, a new
hospital's Medicaid rate shall be one hundred percent (100%) of the weighted
average statewide per diem rate for long term acute care
hospitals until a prospective rate is determined on the hospital's rate setting
cost report, in accordance with section (4).
(D) Rehabilitation hospitals. In the absence
of adequate cost data, a new hospital's Medicaid rate shall be one hundred
percent (100%) of the weighted average statewide per diem rate
for rehabilitation hospitals until a prospective rate is determined on the
hospital's rate setting cost report, in accordance with section (4).
(6) Acuity Adjustment Payment (AAP).
(A) Beginning with SFY 2023, hospitals
that meet the requirements set forth below shall receive an AAP. A hospital
that is designated as a long-term acute care hospital, freestanding psychiatric
hospital, or a free-standing rehabilitation hospital does not qualify to
receive an AAP. Ownership type of the hospital is determined based on the type
of control reported on Schedule S-2, Part I, Line 21, Column 1 of the
hospital's base year cost report. For purposes of this section, Medicaid
payments received shall include the following payments:
1. The Medicaid per diem payments, AAP, PC
payment, and SLP.
2. For SFY 2023
and forward, the Medicaid per diem payments, AAP, PC payment,
SLP, GME payments, and CO payments.
(B) Private ownership. A hospital shall
receive an AAP if the hospital's MO HealthNet case mix index is greater than a
threshold set annually by the division. The preliminary AAP is calculated by
multiplying the hospital's MO HealthNet case mix index times the estimated
Medicaid FFS claims payments for the coming SFY. If the hospital's estimated
Medicaid FFS claims payments for the coming SFY plus the preliminary AAP
exceeds the hospital's prior SFY Medicaid FFS payments received increased by a
stop-gain percentage, the preliminary AAP will be reduced so the estimated
Medicaid FFS claims payments for the coming SFY plus the final AAP is equal to
the stop-gain percent of the hospital's prior SFY Medicaid FFS payments
received. If no reduction is necessary, the preliminary AAP shall be considered
final.
(C) Non-state government
owned or operated (NSGO) ownership. A hospital shall receive an AAP if the
hospital's MO HealthNet case mix index is greater than a threshold set annually
by the division. The preliminary AAP is calculated by multiplying the
hospital's MO HealthNet case mix index times the estimated Medicaid FFS claims
payments for the coming SFY. If the hospital's estimated Medicaid FFS claims
payments for the coming SFY plus the preliminary AAP exceeds the hospital's
prior SFY Medicaid FFS payments received increased by a stop-gain percentage,
the preliminary AAP will be reduced so the estimated Medicaid FFS claims
payments for the coming SFY plus the final AAP is equal to the stop-gain
percent of the hospital's prior SFY Medicaid FFS payments received. If no
reduction is necessary the preliminary AAP shall be considered final.
(D) The annual final AAP will be calculated
for each hospital at the beginning of each SFY. The annual amount will be paid
out over the number of financial cycles during the SFY.
(7) Poison Control (PC) Payment.
(A) The PC payment shall be determined for
hospitals which operated a poison control center during the base year and which
continues to operate a poison control center. The PC payment shall reimburse
the hospital for the Medicaid share of the total poison control cost and shall
be determined as follows:
1. The total poison
control cost from the base year cost re- port will be divided by the total
hospital days from the base year cost report to determine a cost per day. This
cost per day will then be multiplied by the estimated Medicaid FFS and MC days
for the SFY for which the PC payment is being calculated. The estimated
Medicaid FFS and MC days are paid days from the second prior calendar year;
and
2. The annual final PC payment
will be calculated for each eligible hospital at the beginning of each SFY. The
annual amount will be paid out over the number of financial cycles during the
SFY.
(8) Stop Loss Payment (SLP).
(A) Beginning with SFY
2023 hospitals that meet the requirements set forth below shall receive an SLP.
Ownership type of the hospital is determined based on the type of control
reported on Schedule S-2, Part I, Line 21, Column 1 of the hospital's base year
cost report. For purposes of this section, Medicaid payments received shall
include the following payments:
1. The
Medicaid per diem payments, AAP, PC payment, and SLP.
2. For SFY 2023 and forward, the Medicaid
per diem payments, AAP, PC payment, SLP, GME payments, and CO
payments.
(B) Private
ownership. Total estimated Medicaid FFS payments for the coming SFY for each
hospital shall include estimated Medicaid FFS claims payments, and any final
AAP and PC payment. The total estimated Medicaid FFS payments for each hospital
shall be subtracted from the hospital's prior SFY Medicaid FFS payments
received then summed to calculate a total increase or decrease in payments for
the entire private ownership group. A positive result represents a decrease in
payments and a negative amount represents an increase in payments. If the
result is a decrease in total payments to the private ownership group, this
amount shall represent the total stop loss amount.
1. SLP will be made if a total stop loss
amount was calculated in subsection (8)(B). Each hospital that shows a decrease
in Medicaid payments shall receive a SLP in the amount of the decrease in
payments unless the sum of each hospital's SLP is greater than the total stop
loss amount. If the sum is greater than the total stop loss amount, each
hospital's SLP shall be calculated by multiplying the total stop loss amount
times the ratio of the hospital's decrease in Medicaid payments to the total
decrease in payments for the entire private ownership group.
2. Privately owned free-standing psychiatric
hospitals. Total estimated Medicaid FFS payments for the coming SFY for each
hospital shall include estimated Medicaid FFS claims payments, and any final
AAP and PC payment. The total estimated Medicaid FFS payments for each hospital
shall be subtracted from the hospital's prior SFY Medicaid FFS payments
received then summed to calculate a total increase or decrease in payments for
the entire privately owned free-standing psychiatric hospital ownership group.
A positive result represents a decrease in payments and a negative amount
represents an increase in payments.
A. If a
hospital has a decrease in payments as calculated in paragraph (8)(B)2., the
hospital will receive a payment equal to the amount of payment decrease. If the
hospital has an increase in payments as calculated in paragraph (8)(B)2., the
hospital will not receive any additional payments.
(C) NSGO ownership. Total
estimated Medicaid FFS payments for the coming SFY for each hospital shall
include estimated Medicaid FFS claims payments, and any final AAP and PC
payment. The total estimated Medicaid FFS payments for each hospital shall be
subtracted from the hospital's prior SFY Medicaid FFS payments received then
summed to calculate a total increase or decrease in payments for the entire
NSGO ownership group. A positive result represents a decrease in payments and a
negative amount represents an increase in payments. If the result is a decrease
in total payments to the NSGO ownership group, this amount shall represent the
total stop loss amount.
1. SLP will be made
if a total stop loss amount was calculated in subsection (8)(C). Each hospital
that shows a decrease in Medicaid payments shall receive a SLP in the amount of
the decrease in payments unless the sum of each hospital's SLP is greater than
the total stop loss amount. If the sum is greater than the total stop loss
amount, each hospital's SLP shall be calculated by multiplying the total stop
loss amount times the ratio of the hospital's decrease in Medicaid payments to
the total decrease in payments for the entire NSGO ownership group.
(D) The annual SLP will be
calculated for each hospital at the beginning of each SFY. The annual amount
will be paid out over the number of financial cycles during the SFY.
(9) Medicaid Graduate Medical Education (GME) Payments. Effective beginning with SFY 2023, a GME payment calculated as the sum of the intern and resident based GME payment and the GME stop loss payment, shall be made to any acute care hospital that provides graduate medical education.
(A) Intern and
resident (I&R) based GME payment. The I&R based GME payment will be
based on the per I&R Medicaid allocated GME costs not to exceed a maximum
amount per I&R The division will determine the number of full time
equivalent (FTE) I&Rs. Total GME costs will be determined using Worksheet A
of the base year cost report adjusted by the trend index. Total GME costs is
multiplied by the ratio of Medicaid FFS and MC days to total days to determine
the Medicaid allocated GME costs which is then divided by the number of FTE
I&R to calculate the Medicaid allocated cost per I&R The I&R based
GME payment is calculated as the number of FTE I&Rs multiplied by the
minimum established by the division or the Medicaid allocated cost per
I&R
(B) GME stop loss payment.
The total I&R based GME payment for each hospital shall be subtracted from
the hospital's prior SFY GME payments received then summed to calculate a total
increase or decrease in payments for the entire group of hospitals that provide
graduate medical education. A positive result represents a decrease in payments
and a negative amount represents an increase in payments. If the result is a
decrease in total payments to the hospitals, this amount shall represent the
total GME stop loss amount. GME stop loss payments will be made if a total GME
stop loss payment amount was calculated in the paragraph above. Each hospital
that shows a decrease in GME Medicaid payments shall receive a GME stop loss
payment in the amount of the decrease in payments unless the sum of each
hospital's GME stop loss pay- ment is greater than the total GME stop loss
amount. If the sum is greater than the total GME stop loss amount, each
hospital's GME stop loss payment shall be calculated by multiplying the total
GME stop loss amount times the ratio of the hospital's decrease in GME Medicaid
payments to the total decrease in GME Medicaid payments.
(C) Hospitals who implement a GME program
prior to July 1 of the SFY and do not have a base year cost report to determine
GME costs shall receive an I&R based GME payment based on the statewide
average per resident amount (PRA) determined as follows:
1. The number of FTE I&Rs shall be
reported to the division by June 1 prior to the beginning of the SFY in order
to have a GME payment calculated; and
2. The I&R based GME payment shall be
calculated as the number of FTE I&Rs multiplied by the Medicaid capped
statewide average PRA. The Medicaid capped statewide average PRA is calculated
as follows:
A. By applying a straight average
to the list of facility PRA's with the following criteria:
(I) A facility's PRA used in the straight
average shall be the minimum as established by the division or the facility's
actual PRA.
(D) The hospital's I&R based GME payment
plus GME stop loss payment, if applicable, will be calculated for each hospital
at the beginning of each SFY. The annual amount will be paid on a quarterly
basis during the SFY.
(10) Children's Outlier (CO) Payment-
(A) The outlier year is based on a discharge
date between July 1 and June 30;
(B) Beginning July 1, 2022, for
fee-for-service claims only, outlier payments for medically necessary inpatient
services involving exceptionally high cost or exceptionally long lengths of
stay for MO Health Net-eligible children under the age of six (6) will be made
to hospitals meeting the federal DSH requirements in paragraph (10)(B)1. and
for MO HealthNet-eligible infants under the age of one (1) will be made to any
other Missouri Medicaid hospital.
1. The
following criteria must be met to be eligible for outlier payments for children
one (1) year of age to children under six (6) years of age:
A. If the facility offered nonemergency
obstetric services as of December 21, 1987, there must be at least two (2)
obstetricians with staff privileges at the hospital who have agreed to provide
obstetric services to individuals entitled to these services under the Missouri
Medicaid plan. In the case of a hospital located in a rural area (area outside
of a metropolitan statistical area, as defined by the federal Executive Office
of Management and Budget), the term obstetrician includes any physician with
staff privileges at the hospital to perform nonemergency obstetric procedures.
This section does not apply to hospitals either with inpatients predominantly
under eighteen (18) years of age or which did not offer nonemergency obstetric
services as of December 21, 1987;
B. As determined from the base year audited
Medicaid cost report, the hospital must have either-
(I) A Medicaid inpatient utilization rate
(MIUR) at least one (1) standard deviation above the state's mean MIUR for all
Missouri hospitals. The MIUR will be expressed as the ratio of total Medicaid
days (TMD) (including such patients who receive benefits through a managed care
entity) provided under a state plan divided by the provider's total number of
inpatient days (TNID). The state's mean MIUR will be expressed as the ratio of
the sum of the total number of the Medicaid days for all Missouri hospitals
divided by the sum of the total patient days for the same Missouri hospitals.
Data for hospitals no longer participating in the program will be excluded;
or
(II) A
low-income utilization rate (LIUR) in excess of twenty-five percent (25%). The
LIUR shall be the sum (expressed as a percentage) of the fractions, calculated
as follows:
(a) Total MO HealthNet patient
revenues (TMPR) paid to the hospital for patient services under a state plan
plus the amount of the cash subsidies (CS) directly received from state and
local governments, divided by the total net revenues (TNR) (charges minus
contractual allowances, discounts, and the like) for patient services plus the
CS; and
(b) The total amount of the
hospital's charges for patient services attributable to charity care (CC) less
CS directly received from state and local governments in the same period,
divided by the total amount of the hospital's charges (THC) for patient
services. The total patient charges attributed to CC shall not include any
contractual allowances and discounts other than for indigent patients not
eligible for MO HealthNet under a state plan.
2. The following criteria must be met for the
services to be eligible for outlier review:
A.
The patient must be a MO HealthNet-eligible infant under the age of one (1)
year, or for hospitals that meet the federal DSH requirements, a MO
HealthNet-eligible child under the age of six (6) years, as of the date of
discharge; and
B. One (1) of the
following conditions must be satisfied:
(I)
The total reimbursable charges for dates of service must be at least one
hundred fifty percent (150%) of the sum of claim payments for each claim;
or
(II) The dates of service must
exceed sixty (60) days and less than seventy-five percent (75%) of the total
service days were reimbursed by MO HealthNet.
3. Claims eligible for outlier review must-
A. Have been submitted in their entirety for
claims processing; and
B. The claim
must have been paid; and
C. An
annual outlier file, for paid claims only, must be submitted to the division no
later than December 31 of the second calendar year following the end of the
outlier year (i.e., claims for outlier year 2022 are due no later than December
31, 2024).
4. After the
review, reimbursable costs for each claim will be determined using the
following data from the audited Medicaid hospital cost report for the year
ending in the same calendar year as the outlier year (i.e., Medicaid hospital
cost reports ending in 2022 will be used for the 2022 outlier year):
A. Average routine (room and board) costs for
the general and special care units for all days of the stay eligible per the
outlier review; and
B. Ancillary
cost-to-charge ratios applied to claim ancillary charges determined eligible
for reimbursement per the outlier review.
5. The outlier payments will be determined
for each hospital as follows:
A. Sum all
reimbursable costs for all eligible outlier claims to equal total reimbursable
costs;
B. Subtract total claim
payments, which includes MO HealthNet claims payments, third-party payments,
and co-pays, from total reimbursable costs to equal excess cost; and
C. Multiply excess costs by fifty percent
(50%).
(11) Psych Adjustment (PA) Payment.
(A) Beginning with SFY 2024, hospitals that
have FFS psychiatric hospital days as identified in the MMIS shall receive a PA
payment.
1. The PA payment is a set dollar
amount appropriated by the General Assembly pursuant to section
11.770, RSMo, and distributed to
eligible hospitals proportionately as follows:
A. The FFS psychiatric hospital days for each
hospital will be divided by the total FFS psychiatric hospital days for all
hospitals to determine a percentage for each hospital. This percentage will
then be multiplied by the set dollar amount in paragraph (11)(A)1. to determine
the PA payment. The FFS psychiatric hospital days are paid days from the second
prior calendar year.
2.
The annual final PA payment will be calculated for each eligible hospital at
the beginning of each SFY. The annual amount will be paid out over the number
of financial cycles during the SFY.
(12) Safety Net Hospitals.
(A) Inpatient hospital providers may qualify
as a safety net hospital based on the following criteria. Hospitals shall
qualify for a period of only one (1) SFY and must re qualify at the beginning
of each SFY to continue their safety net hospital designation.
1. If the facility offered non-emergency
obstetric services as of December 21, 1987, there must be at least two (2)
obstetricians with staff privileges at the hospital who have agreed to provide
obstetric services to individuals entitled to those services under the Missouri
Medicaid plan. In the case of a hospital located in a rural area (area outside
of a metropolitan statistical area, as defined by the federal executive Office
of Management and Budget), the term obstetrician includes any physician with
staff privileges at the hospital to perform non-emergency obstetric procedures.
This section does not apply to hospitals either with inpatients predominantly
under eighteen (18) years of age or which did not offer non-emergency obstetric
services as of December 21, 1987;
2. As determined from the audited base year
cost report, the facility must have either-
A.
A Medicaid inpatient utilization rate (MIUR) at least one (1) standard
deviation above the state's mean MIUR for all Missouri hospitals. The MIUR will
be expressed as the ratio of total Medicaid days (TMD) (including such patients
who receive benefits through a managed care entity) provided under a state plan
divided by the provider's total number of inpatient days (TNID). The state's
mean MIUR will be expressed as the ratio of the sum of the total number of
Medicaid days for all Missouri hospitals divided by the sum of the total
patient days for the same Missouri hospitals. Data for hospitals no longer
participating in the program will be excluded;
MIUR = TMD / TNID or
B. A low income utilization rate in excess of
twenty-five percent (25%).
(I) The low-income
utilization rate (LIUR) shall be the sum (expressed as a percentage) of the
fractions, calculated as follows:
(a) Total
Medicaid patient revenues (TMPR) paid to the hospital for patient services
under a state plan (regardless of whether the services were furnished on a
fee-for-service basis or through a managed care entity) plus the amount of the
cash subsidies (CS) directly received from state and local governments, divided
by the total net revenues (TNR) (charges minus contractual allowances,
discounts, etc.) for patient services plus the cash subsidies; and
(b) The total amount of the hospital's
charges for patient services attributable to charity care (CC) less cash
subsidies directly received from state and local governments in the same
period, divided by the total amount of the hospital's charges (THC) for patient
services. The total patient charges attributed to charity care shall not
include any contractual allowances and discounts other than for indigent
patients not eligible for medical assistance under a state plan.
LIUR = ((TMPR + CS) / (TNR + CS)) + ((CC - CS) / THC)
3.
As determined from the audited base year cost report-
A. The acute care hospital has an unsponsored
care ratio of at least sixty-five percent (65%) and is licensed for less than
fifty (50) inpatient beds; or
B.
The acute care hospital has an unsponsored care ratio of at least sixty-five
percent (65%) and is licensed for fifty (50) inpatient beds or more and has an
occupancy rate of more than forty percent (40%); or
C. A public non-state governmental acute care
hospital with an LIUR of at least forty percent (40%) and an MIUR greater than
one (1) standard deviation from the mean, and is licensed for fifty (50)
inpatient beds or more and has an occupancy rate of at least forty percent
(40%); or
D. The hospital is owned
or operated by the Board of Curators as defined in Chapter 172, RSMo;
or
E. The hospital is a public
hospital operated by the Department of Mental Health primarily for the care and
treatment of mental disorders.
(13) Hospital Mergers. Hospitals that merge their operations under one (1) Medicare and Medicaid provider number shall have their Medicaid reimbursement combined under the surviving hospital's (the hospital's whose Medicare and Medicaid provider number remained active) Medicaid provider number.
(A) The per
diem rate for merged hospitals shall be calculated-
1. For the remainder of the SFY in which the
merger occurred, the merged rate is calculated by multiplying each hospital's
estimated Medicaid paid days by its per diem rate, summing the
estimated per diem payments and estimated Medicaid paid days, and then dividing
the total estimated per diem payments by the total estimated paid days to
determine the weighted per diem rate. The effective date of
the weighted per diem rate will be the date of the merger; or
2. For subsequent SFYs, the per
diem rate will be based on the combined data from the base year cost
report for each facility.
(B) The other Medicaid payments, if
applicable, shall be-
1. Combined under the
surviving hospital's Medicaid provider number for the remainder of the SFY in
which the merger occurred; and
2.
Calculated for subsequent SFYs based on the combined data from the base year
cost report for each facility.
(14) Payment Assurance. The state will pay each hospital, which furnishes the services in accordance with the requirements of the state plan, the amount determined for services furnished by the hospital according to the standards and methods set forth in the rules implementing the hospital reimbursement program.
(15) Inappropriate Placements.
(A) The hospital per diem rate as determined
under this plan and in effect on October 1, 1981, shall not apply to any
participant who is receiving inpatient hospital care when the participant is
only in need of nursing home care.
1. If a
hospital has an established intermediate care facility/ skilled nursing
facility (ICF/SNF) or SNF-only MO HealthNet rate for providing nursing home
services in a distinct part setting, reimbursement for nursing home services
provided in the inpatient hospital setting shall be made at the hospital's
ICF/SNF or SNF-only rate.
2. No MO
HealthNet payments will be made on behalf of any participant who is receiving
inpatient hospital care and is not in need of either inpatient or nursing home
care.
(16) Directed Payments. Effective July 1, 2022, the Missouri Medicaid managed care organizations shall make inpatient and outpatient directed payments to in-state in-network hospitals pursuant to 42 CFR 438.6(c) as approved by the Centers for Medicare & Medicaid Services.
*Original authority: 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978, 1978, 1981, 1986, 1988, 1990, 1992, 1993, 2004, 2005, 2007, 2011, 2013; 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012; and 208.201, RSMo 1987, amended 2007.
Disclaimer: These regulations may not be the most recent version. Missouri may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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